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Facilities - Capitation and/or Delegation Supplement, 2018 UnitedHealthcare Administrative Guide

Contracted facilities are accountable to provide timely notification to both the delegate and UnitedHealthcare within 24 hours of admission for all inpatient and observation status cases. This includes changes in level of care that impact billing category.

For maternity cases, you must provide notification before the end of the mandated period (48 hours for normal vaginal delivery, or 96 hours for C-section delivery). We require notification if the newborn stays longer than the mother does. In all cases, separate notification is required immediately when a newborn is admitted to the NICU.

The delegate must have a clearly defined process with the facility whereby the facility information on all admissions, updates in member status, and discharge dates are provided to the medical group/IPA and UnitedHealthcare daily.

UnitedHealthcare and the medical group/IPA require timely notification of admission to give us adequate time to verify eligibility, authorize care, including level of care (LOC), and initiate concurrent review and discharge planning. For emergency admissions, you must provide notification once the member’s condition is stabilized in the emergency department. For timely and accurate payment of facility claims we require proper notification on the day of admission.

You must submit authorization logs for all inpatient acute, observation status, Skilled Nursing Facility (SNF) cases, and Denial Logs at least twice a week to the Authorization Log Unit at clinicaloperations@uhc.com or by fax at 866-383-1740.

We also require specific markets to submit Outpatient Prior Authorization Logs. For new submitters, please arrange a Log delivery schedule with the Authorization Log Unit prior to the first submission.

The Authorization Log Unit must agree in writing and in advance with changes to your submission schedule. Any medical group/IPA undergoing a system change or upgrade that may affect delivery of authorization logs must notify the Authorization Log Unit prior to change date and work with us to help ensure a seamless transition.

Logs must include all cases worked between the previous submission and current submission:

  • Cases generated upon admission;
  • Length of stay changes/extensions;
  • Discharged cases; and
  • Completed outpatient prior authorization cases.
    • If there are no applicable cases to report, the medical group/IPA must submit a weekly authorization log indicating either “no activity” or “no admissions” for each of the designated admission service type for the applicable reporting time.

Logs must include the following data elements:

  • Member ID
  • Member name
  • Member date of birth
  • Requesting care provider (name and address, with TIN if available or NPI)
  • Attending/servicing care provider (name and address, with TIN if available or NPI)
  • Facility care provider (name and address, with TIN if available or NPI)
  • Admitting diagnosis (ICD-10-CM or its successor code)
  • Actual admission date
  • Actual discharge date
  • Service start date
  • Service end date
  • Level of care (i.e., bed type, observation status, outpatient procedures at acute facilities)
  • Length of stay (LOS) (i.e., number of days approved, as well as the number of days denied)
  • Procedure/surgery (CPT Code)
  • Discharge disposition
  • Planned admission date
  • Planned discharge date
  • Service type
  • Authorization number (if available)

The medical group/IPA must have a clearly defined process for determining medical necessity and authorizing outpatient services, which were paid as either shared risk or plan risk per the medical group/IPA contract.

The medical group/IPA must be capable of submitting, pursuant to plan demand, authorization or denials for all shared risk or plan risk services for which the group has authorized or denied care on behalf of UnitedHealthcare.

A member is stabilized or stabilization has occurred when, in the opinion of the treating care provider, the member’s medical condition is such that, within reasonable medical probability, no material deterioration of the member’s condition is likely to result from, or occur during, a transfer of the member. UnitedHealthcare and any of its delegates must:

  • Have a process to respond to requests for poststabilization care;
  • Respond to requests for authorization of poststabilization services within 30 minutes for Commercial and within one hour (60 minutes) for Medicare Advantage members;
  • If UnitedHealthcare or our delegate does not respond within the required time frame, care is viewed as authorized until:
    • Member is discharged,
    • A network care provider arrives and assumes responsibility for the member’s care, or
    • Treating care provider and the organization, defined as the plan or its delegate, agree to another arrangement

Based on the contract, the delegated entity may be financially responsible for:

  • ER and post-stabilization services in area
  • Out of Area (OOA) Services

Post-Stabilization Care (MA)
CMS defines post-stabilization care as services that are:

  • Related to an emergency medical condition,
  • Provided after a member is stabilized, and
  • Provided to maintain the stabilized condition, or under certain circumstances to improve or resolve the member’s condition.

UnitedHealthcare or its delegates must:

  • Have a process to respond to requests for poststabilization care, and
  • Respond to requests for authorization of poststabilization services within one hour.

If UnitedHealthcare or the the delegated entity does not respond within one hour, care is considered authorized until:

  • Member is discharged,
  • A network care provider assumes responsibility for the member’s care either at the treating facility or through transfer, or
  • Treating care provider and the organization, defined as the plan or its delegate, agree to another arrangement.

Based on the participation agreement, the delegate is financially responsible for:

  • ER and post-stabilization services in area, and
  • OOA services if responsible for OOA per the participation agreement.

Typically, observation status is used to rule out a diagnosis or medical condition that responds quickly to care. Facility observation status is generally designed to assess a member’s medical condition to determine the need for inpatient admission, or to stabilize a member’s condition. UnitedHealthcare or our delegate will authorize facility observation status when medically indicated and the case meets nationally recognized evidenced based guidelines. A member’s outpatient observation status may later be changed to an inpatient admission if medically necessary and if appropriate criteria have been met.

We expect our medical management delegates to support compliance with the review of criteria. The delegated medical group/IPA must issue a facility denial when the Inpatient stay does not meet nationally recognized evidence based guideline, when:

  1. It receives notification of the admission;
  2. It receives a post-service request for admission authorization prior to claims submission and it determines that the admission does not meet medical necessity criteria, including relevant Medicare inpatient admission requirements, and is not on the CMS list of HCPCS codes that would be paid only as inpatient procedures; or,
  3. There is no inpatient order that matches the date of the inpatient admission for Medicare members.

When we delegate services for authorization and concurrent review, we expect the delegate to issue a facility denial letter to the contracted facility when the facility’s medical record or claim fails to support the level of care or services rendered. This may be determined through concurrent or retrospective review. There are three types of facility denial letters:

• Delay in inpatient services

• Delay in change of level of care within the same facility

• Delay in facility discharge

The delegated medical group/IPA must comply with our protocols, policies and procedures for denials, including turn-around times for issuing, delivering and submitting facility denial letters to UnitedHealthcare.

When UnitedHealthcare has the responsibility to pay facility services, the delegated medical group/IPA must comply with UnitedHealthcare’s protocols, policies and procedures for submitting facility denial letters to UnitedHealthcare. Whether UnitedHealthcare or its delegate issues the denial, the UnitedHealthcare Provider Dispute Resolution process will be used.

If the delegated medical group/IPA has the responsibility for payment of inpatient facility services, then the delegate need not submit copies of facility denials to UnitedHealthcare. Facility denials are not sent to the member and must specifically exclude the member from liability for the denied level of care and/or services. Under these circumstances, any care provider facility disputes managed by the delegated medical group/IPA’s care provider dispute resolution process.

A facility denial letter is available if requested by the member.

This policy applies if UnitedHealthcare has financial responsibility for the following outpatient MA services. PRIOR AUTHORIZATION IS REQUIRED for:

  • Intensity Modulated Radiation Therapy (IMRT)
  • Stereotaxic Radiosurgery (SRS)
  • Stereotaxic Body Radiation Therapy (SBRT)

We use National Coverage Decision, Local Coverage Decision and UnitedHealthcare medical policies and guidelines to determine eligibility of coverage. Authorization is required prior to the start of therapy and each time a patient starts a new IMRT, STS or SBRT treatment regimen.

Looking for a list of CPT and HCPCS Codes requiring authorization?

Please refer to UHCprovider.com/Oncology > Medicare Advantage Therapeutic Radiation

Prior Authorization Required for Payment to be Processed

You can initiate a request for prior authorization of outpatient therapeutic radiation services (IMRT, STS, and SBRT) carved out of capitation on UHCprovider.com/priorauth. We do not process the request or make a determination until we have received all necessary information. Once we receive all the necessary information requested, we make a decision within the applicable timeframe.

We authorize therapeutic radiation services following the member’s benefit design provided the member does not exceed their benefit restrictions.

eviCore is our nationally contracted vendor for utilization management to administer the prior authorization program for Therapeutic Radiation Services (IMRT, SRS and SBRT). eviCore uses the NCDs, LCDs and the UnitedHealthcare Medicare Advantage Coverage Summaries for managing the program.

We will fax a written communication of case resolution to the medical group/IPA for each case serviced. Denials require a letter sent to both member and care provider stating the reason why the requested service denied and outlining the process for filing standard and expedited appeals.

Delegates that receive requests for services must make decisions and provide notification within applicable regulatory and accreditation time frames. We hold the delegate to the most stringent requirements for approvals, extensions of decision turnaround times, denials, delays, partial approvals and modification of requested services.

You can find additional information outlined in Chapter 6: Medical Management, Medical Management Denials/Adverse Determinations.

Find address and contact information for medical management appeals

Look in the Resources and How to Contact Us table in Chapter 1: Introduction, or similar tables in the applicable supplement.

Qualifications of Who Can Deny or Make Adverse Determinations

Only physicians or appropriately licensed clinical personnel can deny or make adverse determinations based on medical necessity. This “physician reviewer” may be a physician, doctoral level clinical psychologist or pharmacist as appropriate to the requested service.

The physician reviewer must have a current unrestricted license. Delegates must provide evidence of verification according to credentialing requirements.

For MA, the delegate must verify that the physician reviewer has experience showing knowledge of Medicare coverage criteria. Evidence of verification may include content of curriculum vitae, training as part of on-boarding process, training after on-boarding, or interaction between our Medical Director and the delegate’s physician reviewers. Evidence may also include review of denial records or files indicating appropriate use of criteria applicable to the request for services and member’s condition.

Oral or Verbal Notification

There are various requirements for oral or verbal notification of approvals or denials. This may vary from state to state or by request type (such as pre-service, expedited or concurrent). The delegate must document efforts to provide oral notification and meet written notification requirements as well.

Written Denial Notice

The written denial is an important part of the member’s chart and the delegate’s records. Regardless of the form used, the denial letter documents member and care provider notification of:

  • The denial, delay, partial approval or modification of requested services.
  • The reason for the decision, including medical necessity, benefits limitation or benefit exclusion.
  • Member-specific information about how the member did not meet criteria.
  • Appeal rights.
  • An alternative treatment plan, if applicable.
  • Benefit exhaustion or planned discharge date, if applicable.

CMS requires the use of the CMS Integrated Denial Notice/Notice of Denial of Medical Coverage (IDN/NDMC) for Medicare Advantage and Medicaid plan members. Do not alter this template except to add text to the requested areas.

Most states require approved standardized templates for member notices, such as denial of services. UnitedHealthcare will provide appropriate and approved templates to the delegates.

Minimum Content of Written or Electronic Notification

A notice to deny, delay or modify a health care services authorization request must include the following:

  • The requested service(s)
  • A reference to the benefit plan provisions to support the decision
  • The reason for denial, delay, modification, or partial approval, including:
    • Clear, understandable explanation of the decision
    • Name and description of the criteria or guidelines used
    • How those criteria were applied to the member’s condition
  • A statement that the member can get a free copy of the benefit provision, guideline, protocol or other criterion used to make the denial decision
  • Contractual rationale for benefit denials
  • Alternative treatments offered, if applicable
  • A description of additional information needed to complete that request and why it is necessary (for delay of decision)
  • Appeal and grievance processes, including:
    • When, when, how and where to submit a standard or expedited appeal
    • The member’s right to appoint a representative to file the appeal
    • The right to submit written comments, documents or other additional relevant information
    • The right to file a grievance or appeal with the applicable state agency, including information regarding the independent medical review process (IMR), as applicable
  • The name and phone number of the health care professional responsible for the decision included in the care provider’s notice. This is not required in the member’s notification.
  • Any state-mandated language (Commercial or Medicaid)
  • ERISA information as applicable (Commercial)
  • Ombudsman information (Commercial)

In April 2016, CMS published two job aids to address the source of most of CMS’s audit findings:

When Processing Medicare Part C Organization Determinations and Reconsiderations, What’s Reasonable Outreach?

  • First, decide if expedited or standard decision is needed, the type or level of service requested and if any information is missing or needed for approval.
  • If additional information is missing or needed, reach out to the provider. This is recommended within a few hours of receiving the request. Notify the provider of the specific information needed to approve coverage. Document the date/time and method of all outreach attempts. Document the success of the outreach; that is, all requested missing information is obtained.
  • Make at least two additional attempts, using different methods from your initial outreach (e.g., phone, fax, automated system or a letter). Make requests within business hours; if not feasible, follow the provider’s after-hours instructions on their voicemail or answering service. Leave at least a few hours for the provider to respond and after final outreach attempt prior to issuing a decision.
  • If you made at least three outreach attempts, used different methods of outreach, and thoroughly document all attempts.

Medicare Part C Denial Notice Rationale

Information Needed to Approve Coverage (extension)

  • List specific diagnosis or clinical criteria required, if any.
  • Give details on the clinical information needed from the provider to approve coverage of the requested item or service.
  • Provide relevant information from the plan’s Evidence of Coverage or Medicare coverage policy, if appropriate.

Writing the denial rationale:

  • Use the OMB-approved Notice of Denial of Medicare Coverage (NDMC)
  •  Know the type and level of service requested
  • Determine the denial type, such as medical necessity or benefit exclusion
  • List any criteria used from the plan’s Evidence of Coverage, Medicare or CMS-approved Plan coverage criteria, or any other criteria used in making the decision.
  • Rationale should match the case notes on why the request was denied and be appropriate to each specific case.
  • Write in plain language easily understandable by an enrollee, and tailored appropriately to the enrollee (e.g., Spanish speaking or large print).

If your denial rationale follows these steps and it has all the information needed to approve coverage, then your denial rationale is sufficient.

In February 2017, CMS published a memo about Updated Guidance on Outreach for Information to Support Coverage Decisions, relating to the job aid about “What’s Reasonable Outreach?” This memo identified best practices that would result in more timely and accurate coverage decisions for Medicare Advantage enrollees. Since CMS plans to update the Medicare Managed Care Manual Chapter 13 to include these as requirements, we have included the best practices in the annual assessment process so that our delegates are prepared in advance to implement them when they become requirements.

  • Standard pre-service organization determinations: make at least three outreach attempts, the first within two calendar days of receipt of request and during the provider’s business hours when feasible.
  • Expedited preservice organization determinations: make at least three outreach attempts, the first upon receipt of request and during the provider’s business hours when feasible.
  • The memo provides additional details on “Outreach Methods and Involvement of Plan Physicians” and “Documenting Requests for Information.”

We may delegate the functions of complex case management or disease management. Requirements are based on NCQA accreditation standards. In the case of Community Plans, delegation may include statespecific requirements around CCM, variously called care coordination or care management. In this context, the requirements differ from medical management. Some Community Plans may have additional disease management requirements.

If these functions are delegated to a medical group/IPA or other organization, we will conduct pre-contractual and post-contractual assessments. If assessments identify deficiencies, we will require delegates to undergo improvement action. The oversight process mirrors the delegation oversight process for Medical Management.

The US Department of Health and Human Services published final non-discrimination rules from Section 1557 of the Affordable Care Act. The final rule clarifies and codifies existing nondiscrimination requirements and sets forth standards for including non-discrimination notices on significant communications sent to health plan members. This includes, but is not limited to member facing letters (example: IDN, NOMNC, service denials), documents, notices, newsletters, and brochures that are sent to the member.

UnitedHealthcare has provided the delegates with our required taglines - a short form and a long form. The delegate is required to attach the short form to communications one to two pages in length and the long form to communications three or more pages in length. The tagline need not be added into the body of the communication but may be included as a separate sheet in the mailing envelope. Only a single tagline sheet need be included in every mailing, even if the envelope contains multiple communications.